BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

On the Configurational and Conformational Changes in Photoactive Yellow Protein that Leads to Signal Generation in Ectothiorhodospira halophila

Photoactive Yellow Protein (PYP), a phototaxis photoreceptor from Ectothiorhodospira halophila, is a small water-soluble protein that iscrystallisable and excellently photo-stable. It can be activated with light(λ(max)= 446 nm), to enter a series of transientintermediates that jointly form the photocycle of this photosensor protein.The most stable of these transient states is the signalling state forphototaxis, pB.The spatial structure of the ground state of PYP, pG and the spectralproperties of the photocycle intermediates have been very well resolved.Owing to its excellent chemical- and photochemical stability, also the spatialstructure of its photocycle intermediates has been characterised with X-raydiffraction and multinuclear NMR spectroscopy. Surprisingly, the resultsobtained showed that their structure is dependent on the molecular contextin which they are formed. Therefore, a large range of diffraction-,scattering- and spectroscopic techniques is now being employed to resolvein detail the dynamical changes of the structure of PYP while it progressesthrough its photocycle. This approach has led to considerable progress,although some techniques still result in mutually inconsistent conclusionsregarding aspects of the structure of particular intermediates.Recently, significant progress has also been made with simulations withmolecular dynamics analyses of the initial events that occur in PYP uponphoto activation. The great challenge in this field is to eventually obtainagreement between predicted dynamical alterations in PYP structure, asobtained with the MD approach and the actually measured dynamicalchanges in its structure as evolving during photocycle progression.

The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity

BACKGROUND

It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands.

STUDY DESIGN AND METHODS

Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100,000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group.

RESULTS

The observed MMR was 13 per 100,000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100,000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0).

CONCLUSIONS

It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings.

Spontaneous ilio-iliac arteriovenous fistula due to an iliac artery aneurysm: a case-report

A spontaneous arterio-venous ilioiliac fistula (AVF) caused by an iliac artery aneurysm (IAA) is a rare complication. We present the case of a 75-year-old man with previous aortic surgery 11 years before who was admitted at the Emergency Department for acute gluteal pain. He was suspected for a hip problem because of cup loosening on X-ray. A lumbar CT-scan to rule out nerve compression showed an aneurysm of the left common and internal iliac artery that was ruptured into the iliac vein. The AVF was treated endovascularly under local anesthesia by a sandwich technique (covered stent at the venous side and coils at the arterial side) with good results. The case demonstrates that lifelong follow-up of a patient with previous aortic surgery is mandatory.

Restaging the mediastinum in non-small cell lung cancer after induction therapy: non-invasive versus invasive procedures

OBJECTIVE

Nodal status after induction therapy in patients with stage III non-small cell lung cancer (NSCLC) is an independent prognostic factor for survival. Prognosis is poor in patients with persisting mediastinal lymph node involvement.

METHODS

From February 2000 to September 2007, restaging for NSCLC was performed in 25 patients (23 men, 2 women) by computed tomography (CT), positron emission tomography (PET) as well as repeat mediastinoscopy. Initial proof of N2 or N3 disease was obtained by mediastinoscopy.

RESULTS

The non-invasive restaging modalities CT and PET had a rather low accuracy of 64% and 72%, respectively. Repeat mediastinoscopy performed better with an accuracy of 84%.

CONCLUSION

Histological proof of mediastinal involvement after induction therapy in NSCLC is necessary to select those patients who will benefit from surgical resection. When a first mediastinoscopy has been performed to obtain pathological proof of N2 or N3 disease, repeat mediastinoscopy proves to be more accurate than CT or PET scanning for mediastinal restaging.

On the midpoint potential of the FAD chromophore in a BLUF-domain containing photoreceptor protein

The redox-midpoint potential of the FAD chromophore in the BLUF domain of anti-transcriptional regulator AppA from Rhodobacter sphaeroides equals ∼-260mV relative to the calomel electrode. Altering the structure of its chromophore-binding pocket through site-directed mutagenesis brings this midpoint potential closer to that of free flavin in aqueous solution. The redox-midpoint potential of this BLUF domain is intermediate between those of LOV domains and Cryptochromes, which may rationalize the primary photochemistry observed in these three flavin-containing photoreceptor families. These results also imply that LOV domains, among the flavin-containing photosensory receptors, are least sensitive to intracellular chemical reduction in the dark.

In vivo effects on photosynthesis gene expression of base pair exchanges in the gene encoding the light-responsive BLUF domain of AppA in Rhodobacter sphaeroides

The Rhodobacter sphaeroides protein AppA has the unique quality of sensing and transmitting light and redox signals. By acting as antirepressor to the PpsR protein, it acts as a major regulator in photosynthesis gene expression. In this study, we show that by introducing amino acid exchanges into the AppA protein, the in vivo activity as an antirepressor can be greatly altered. The tryptophan 104 to phenylalanine (W104F) base exchange greatly diminished blue-light sensitivity of the BLUF domain. From the obtained in vivo data, the difference in thermal recovery rate of the signaling state of the BLUF domain between the wild type and mutated protein was calculated, predicting an about 10-fold faster recovery in the mutant, which is consistent with in vitro data. Introduction of a tyrosine 21 to phenylalanine (Y21F) or to cysteine (Y21C) mutation led to a complete loss of AppA antirepressor activity, while additionally leading to an increase of photosynthesis gene expression after illumination with high blue-light quantities. Interestingly, this effect is not visible in a W104F/Y21F double mutant that again shows a wild-type-like behavior of the BLUF domain after blue-light illumination, thus restoring the activity of AppA.

Dissociation kinetics of the GroEL-gp31 chaperonin complex studied with Förster resonance energy transfer

Propagation of bacteriophage T4 in its host Escherichia coli involves the folding of the major capsid protein gp23, which is facilitated by a hybrid chaperone complex consisting of the bacterial chaperonin GroEL and the phage-encoded co-chaperonin, gp31. It has been well established that the GroEL-gp31 complex is capable of folding gp23 whereas the homologous GroEL-GroES complex cannot perform this function. To assess whether this is a consequence of differences in the interactions of the proteins within the chaperonin complex, we have investigated the dissociation kinetics of GroEL-gp31 and GroEL-GroES complexes using Forster resonance energy transfer. Here we report that the dissociation of gp31 from GroEL is slightly faster than that of GroES from GroEL and is further accelerated by the binding of gp23. In contrast to what had been observed previously, we found that gp23 is able to interact with the GroEL-GroES complex, which might explain how bacteriophage T4 redirects the folding machinery of Escherichia coli during morphogenesis.

Surgical resection of lung metastases including the role of locoregional therapy

Although no randomized trials are available, surgical resection is a widely accepted treatment for selected patients with pulmonary metastases. Specific criteria have been well defined and a macroscopic complete resection should be obtained. Important prognostic factors include histology, number of metastases and disease-free interval. However, even after complete resection, 5-year survival rates remain disappointingly low and many patients will have recurrent disease confined to the chest. For this reason, locoregional therapies are extensively investigated at the present time. These include biochemical and biophysical methods. Due to toxicity of high doses of intravenous chemotherapy, the main purpose is to deliver high-dose chemotherapy to the lung without systemic side-effects. Chemo-embolization, pulmonary artery infusion and isolated lung perfusion are most intensively studied. These techniques were found to be feasible and are able to deliver a high local concentration of chemotherapeutic drugs. The results of further phase II trials are awaited for to determine their effect on local recurrence and long-term survival.

Quality of life after lung cancer surgery: a review

The long-term goals of lung cancer surgery include cancer control, survival and quality of life (QoL). In a patient population with a high mortality rate, evaluation and preservation of QoL after treatment is imperative. Lung cancer patients already have a significant lower QoL compared to an age-matched healthy population with significant impairment in physical and emotional functioning. Lung cancer surgery causes further deterioration of QoL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 and 12 months after surgery. Age, extent of surgery, preoperative lung function, access technique, and adjuvant treatment may all influence postoperative QoL. This review presents the basic concepts of QoL research, several commonly used QoL measurement instruments, and a summary of the available data on post-lung cancer surgery QoL.

Different indications for repeat mediastinoscopy: single institution experience of 79 cases

AIM

Different indications exist for repeat mediastinoscopy or remediastinoscopy (reMS). Presently, it is a valuable restaging tool in non-small cell lung cancer (NSCLC). Not only does it provide pathological evidence of mediastinal downstaging, it also selects those patients who will benefit from a subsequent surgical resection and determines prognosis. However, other indications for reMS exist. The authors reviewed their overall experience with reMS.

METHODS

From June 1994 until September 2007, 79 reMS were performed in 75 patients (65 men and 10 women). Mean age was 67.4 years (range 35 to 85 years).

RESULTS

ReMS was performed after induction therapy in 54 cases (68.4%), for recurrent lung cancer in 7 cases (8.9%), metachronous second primary lung cancer in 2 cases (2.5%), for lung cancer occurring after an unrelated disease such as sarcoidosis in 1 case (1.2%), for an inadequate first procedure in 8 cases (10.1%) and for a non-malignant disease such as sarcoidosis or lymphoma in 7 cases (8.9%). ReMS was technically feasible in all patients. There was no mortality. One hemorrhage was encountered from a bronchial artery during reMS which was controlled by packing and one tear in the bronchial wall which was treated conservatively. In patients with lung cancer (71 patients), reMS was positive in 29 cases (40.8%). ReMS provided a definitive diagnosis in 3 patients with sarcoidosis and in one patient with lymphoma .

CONCLUSIONS

Although mostly performed as a restaging procedure after induction therapy in non-small cell lung cancer, reMS can also safely be performed for other indications providing pathological evidence of mediastinal involvement.

Early endothelial dysfunction in young type 1 diabetics

OBJECTIVES

Endothelial dysfunction is a known precursor of atherosclerosis and can be assessed by measuring the brachial artery flow-mediated dilatation (FMD) via ultrasonography. This study investigated endothelial function in young type 1 diabetics without cardiovascular morbidity or diabetes-related pathology.

METHODS

Young diabetics and healthy controls were recruited, both meeting strict inclusion and exclusion criteria. To prove absence of subclinical atherosclerosis, intima-media thickness (IMT) measurements at the carotid bifurcation were done in all of them. FMD was measured at the brachial artery. The results were compared using the t-test and the influences of different variables on FMD were assessed using multiple linear regression.

RESULTS

Twenty-six diabetics (23.4+/-5.8 years) and 36 healthy volunteers (23.1+/-2.8 years) were recruited. The duration of diabetes was 9.2+/-5.3 years; metabolic control was moderate (HbA1c 7.6+/-1.0%) and IMT was normal in both groups. FMD was significantly impaired in type 1 diabetics (7.13+/-0.43 vs. 8.77+/-0.43%; p=0.002). The FMD grade was associated with diabetes and age. Patients with a good metabolic control (HbA1c</=7.0%) had a better FMD.

CONCLUSIONS

In type 1 diabetics, even without preclinical or clinical atherosclerosis, endothelial function is already disturbed and can be detected using ultrasonography.

[Stage III NSCLC. The surgeon's role in exploration and treatment]

The role of surgery in stage IIIA non-small cell lung cancer (NSCLC) remains controversial. Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive, invasive and alternative or minimally invasive techniques. Remediastinoscopy provides pathological evidence of response after induction therapy. Stage IIIA-N2 NSCLC represents a heterogeneous spectrum of locally advanced disease and different subsets exist. When N2 disease is discovered during thoracotomy a resection should be performed if this can be complete. Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy. In two large, recently completed, phase III trials there was no difference in overall survival between the surgical and radiotherapy arm. Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy. Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet. Also, stage IIIB is mostly treated by concurrent or sequential chemoradiotherapy. Surgery is rarely indicated in T4N0-1 disease unless a complete resection can be obtained, in some selected cases after induction therapy.

High-resolution genetic mapping of mammalian motor activity levels in mice

The generation of motor activity levels is under tight neural control to execute essential behaviors, such as movement toward food or for social interaction. To identify novel neurobiological mechanisms underlying motor activity levels, we studied a panel of chromosome substitution (CS) strains derived from mice with high (C57BL/6J strain) or low motor activity levels (A/J strain) using automated home cage behavioral registration. In this study, we genetically mapped the expression of baseline motor activity levels (horizontal distance moved) to mouse chromosome 1. Further genetic mapping of this trait revealed an 8.3-Mb quantitative trait locus (QTL) interval. This locus is distinct from the QTL interval for open-field anxiety-related motor behavior on this chromosome. By data mining, an existing phenotypic and genotypic data set of 2445 genetically heterogeneous mice (http://gscan.well.ox.ac.uk/), we confirmed linkage to the peak marker at 79 970 253 bp and refined the QTL to a 312-kb interval containing a single gene (A830043J08Rik). Sequence analysis showed a nucleotide deletion in the 3' untranslated region of the Riken gene. Genome-wide microarray gene expression profiling in brains of discordant F(2) individuals from CS strain 1 showed a significant upregulation of Epha4 in low-active F(2) individuals. Inclusion of a genetic marker for Epha4 confirmed that this gene is located outside of the QTL interval. Both Epha4 and A830043J08Rik are expressed in brain motor circuits, and similar to Epha4 mutants, we found linkage between reduced motor neurons number and A/J chromosome 1. Our findings provide a novel QTL and a potential downstream target underlying motor circuitry development and the expression of physical activity levels.